Medical Policy Clinician

Cambia Health Solutions; Provo (UT); Remote; USD 51,000 - 69,000; Full time

Job summary

Cambia Health Solutions in the United States is seeking a Behavioral Health Utilization Management Clinician to perform prospective, concurrent, and retrospective reviews from a remote work setup across Oregon, Washington, Idaho, or Utah. You will apply clinical criteria to determine medical necessity, collaborating with physician advisors to ensure quality and appropriate payments.

The role requires a Master’s degree in Behavioral Health and 3+ years of utilization management plus independent

Qualifications

• Master's degree in Behavioral Health required.
• 3 years of utilization management or behavioral health care management experience.
• 3 years direct Behavioral Health clinical experience as an independently licensed Master's level clinician.
• Proficiency with Microsoft Office, Outlook, and internet search.
• Familiarity with electronic health documentation systems.
• Strong verbal, written, and interpersonal communication with a focus on customer service.
• Ability to interpret and explain complex policies to stakeholders.
• Experience in inpatient hospitals, residential facilities, or partial hospital programs.

Responsibilities

• Perform comprehensive utilization management reviews to ensure medical necessity and policy standards.
• Apply clinical expertise and evidence-based criteria to make determinations, consulting with physician advisors as needed.
• Provide prompt, accurate responses to internal and external inquiries.
• Identify opportunities for quality improvement and participate in related initiatives.
• Maintain meticulous documentation and prioritize assignments to meet performance standards.
• Uphold confidentiality and communicate professionally with members, providers, and regulators.

Skills

Utilization management

BH clinical experience

Advanced BH settings

Industry knowledge

MS Office

EHR familiarity

Communication skills

Policy communication

Education

Master's in Behavioral Health

Job description

Behavioral Health Utilization Management Clinician Work from home within Oregon, Washington, Idaho or Utah

Join our Cause to create a person-focused and economically sustainable health care system.

Every day, Cambia's dedicated team of Clinicians are living our mission to make health care easier and lives better. As a member of the Behavioral Health team, our Clinicians provide utilization management (such as prospective concurrent and retrospective review) to best meet the member's specific healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services - all in service of making our members' health journeys easier.

Are you a licensed Clinician with a passion for Utilization Management wanting to make a career change? Are you wanting to make positive change in people's lives and healthcare? Master's Degree in Behavioral Health Discipline.

• 3 years of utilization management or behavioral health care management experience
• 3 years direct Behavioral Health clinical experience as an independently licensed Master's level Behavioral Health Clinician in one of the areas of Psychology, Counselling, Social Work, Marriage or Family Therapy
• Proficiency in advanced behavioral healthcare settings, including inpatient hospitals, residential facilities, and partial hospital programs
• Staying abreast of the latest developments in the health insurance industry, including trends, technological advancements, and contractual agreements
• Proficient in general computer skills, including Microsoft Office, Outlook, and internet search capabilities
• Familiarity with electronic healthcare documentation systems and their applications
• Possessing exceptional verbal, written, and interpersonal communication skills, with a strong focus on customer service and support
• Ability to accurately interpret and effectively communicate complex policies and procedures to various stakeholders

Performs comprehensive utilization management reviews, encompassing prospective, concurrent, and retrospective assessments, to ensure adherence to medical necessity and policy standards.

Applies clinical expertise and evidence-based criteria to make informed determinations, consulting with physician advisors as necessary to ensure accuracy.

Serves as a trusted resource, providing prompt and accurate responses to internal and external inquiries, ensuring exceptional customer service.

Identifies opportunities for improvement and actively participates in quality improvement initiatives to drive excellence.

Maintains meticulous and consistent documentation, prioritizing assignments to meet performance standards and corporate objectives.

Upholds the confidentiality of sensitive information and communicates professionally with members, providers, and regulatory organizations, ensuring data protection and integrity.

#LI-Remote

The expected hiring range depends on skills, experience, education, and training; and performance history.

Oregon, Washington, Utah, and Idaho: The expected hiring range is $36.80 - $49.80 an hour, the full salary range is $34.20 - $55.70 an hour and the bonus target is 8%.

Work alongside diverse teams building cutting-edge solutions to transform health care.

Grow your career with a company committed to helping you succeed.

Give back to your community by participating in Cambia-supported outreach programs.

Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

In exchange for helping members live healthy lives, we offer benefits that empower you to do the same.

Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more.

We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb.

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).

All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law.

If you need accommodation for any part of the application process because of a medical condition or disability, please email about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.